Healthcare Provider Details

I. General information

NPI: 1689539892
Provider Name (Legal Business Name): ELLISA WYRWICKI RN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 CEAPE AVE
OSHKOSH WI
54901-5480
US

IV. Provider business mailing address

1363 CEAPE AVE
OSHKOSH WI
54901-5480
US

V. Phone/Fax

Practice location:
  • Phone: 920-264-8433
  • Fax:
Mailing address:
  • Phone: 920-264-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1124100-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: